Transcript Understanding Medication Assisted Treatment

HELP. HOPE. HEALING.
Understanding Medication
Assisted Treatment
Joan R. Shepherd, FNP
The Coleman Institute
Addictive Drugs Actually Overtake the Pleasure
Center
• Some addictive drugs release over 5 times the
Dopamine that is meant to be released
HELP. HOPE. HEALING.
• Monkeys in experiments with unlimited access
to IV cocaine will keep using it until they die of
starvation
• Human patients with addiction will eventually:
• Use their drugs instead of food
• Use their drugs instead of sex
• Use their drugs in spite of hurt to their
families and loved ones
• Use their drugs in spite of harming
themselves
Most People Can Handle Alcohol and Drugs That
Release Extra Dopamine – but 10% Have Trouble
Handling These Drugs
HELP. HOPE. HEALING.
• They most likely have inherited a slight deficiency of the
reward system
• Some evidence that addicts have a Dopamine D2 Receptor
Deficiency:
• They seem to experience very strong pleasure from
addictive drugs
• They put up with negative consequences
• They change their priorities
• Denial and rationalization keep the process going
Cravings and Relapse
There are four basic causes:
1. The brain has not fully healed
HELP. HOPE. HEALING.
2. Use of other drugs that release Dopamine
3. Triggers – memory circuits
4. Strong Emotions
HELP. HOPE. HEALING.
PET Scan Showing PAWS
Traditional Treatment Options
1. Drug free – abstinence-based treatment
HELP. HOPE. HEALING.
2. Methadone maintenance
3. Suboxone maintenance
HELP. HOPE. HEALING.
Drug Free – Abstinence-Based Treatment
•
This would be ideal if it worked… but, it doesn’t
work well
•
First, the patient needs detoxification – which is
frequently unsuccessful
•
Second, the patient needs rehabilitation – which is
frequently unsuccessful because the pull back to the
drugs is extremely strong
HELP. HOPE. HEALING.
Abstinence Based Treatment (without medication
assistance) has a Very Low Success Rate
•
The first IOP where Dr. C was Medical Director had 0%
success
•
Seattle study had 3% success after only three months;
other studies have less than 20% success after only six
months
•
There are a number of reasons:
• The brain takes about a year to heal
• Most people are exposed to multiple triggers every day
• Most people have a lot of stress in early recovery
• Opiate drugs are very “clean” – low side effects
HELP. HOPE. HEALING.
Methadone Maintenance
•
It does decrease street drug use and decrease HIV rates
•
But, it has significant problems:
• People need to go to a special clinic – often daily
• People must continue to associate with using people
• Travel is very difficult
• Many people continue to abuse other drugs
• It has effects on weight, teeth, testosterone and
cardiac rhythm
• It is harder to detoxify off methadone than other drugs
•
Over 92% of patients who are on methadone would rather
be free from having to take it
HELP. HOPE. HEALING.
Suboxone Maintenance – Advantages
•
Has been available since 2003
•
It is convenient
• Available in private physician’s offices
• Often only monthly visits
• Sometimes paid for by insurance
•
It does decrease cravings and opiate use
•
It is safer in terms of overdose potential
HELP. HOPE. HEALING.
Suboxone Maintenance – Disadvantages
•
It is now widely abused on the street
•
Many patients continue to abuse other drugs
•
Many patients skip doses or sell their Suboxone and
continue to get high
•
Extremely difficult to detoxify off even low doses
HELP. HOPE. HEALING.
Newer Treatment - Naltrexone
Antagonist Assisted Abstinence
•
Completely blocks the brain’s opiate receptors
•
Dramatically reduces cravings
•
Makes relapse virtually impossible
•
Provides time for patients to be able to make the difficult
changes necessary for long term recovery
• Acceptance
• Understanding – relapse, triggers, emotions
• Attitude changes
• Ability to deal with emotions
• Environmental and Social change
• Spiritual change
HELP. HOPE. HEALING.
Antagonist Assisted Abstinence - Contd
•
Can be started only after detoxification is
complete
•
Oral tablets are less effective
•
Monthly Injections available – Vivitrol
•
Subcutaneous implants last two months
HELP. HOPE. HEALING.
Detoxification Options
•
Cold Turkey – very difficult
•
In-patient Detoxification – expensive and only about 50%
successful
•
Substitution with Methadone – can only be done in a
licensed clinic; success rates are very low
•
Substitution with Suboxone – success rates are very low
•
Ultra-Rapid Detoxification (Anesthesia) – some risks
We Have Developed an Accelerated Detoxification Method
HELP. HOPE. HEALING.
Accelerated Opiate Detoxification
•
Treated more than 5,000 patients over the last 13 years
•
Outpatient environment
•
Extremely Successful - 99% complete the detoxification
•
Usually completed in only three days
•
Very safe
•
Comfortable – most report it is the most comfortable
detoxification they have ever experienced
Our Treatment Provides a Safe, Comfortable and
Effective Solution
HELP. HOPE. HEALING.
Usual Level
Level of
Opiates
in Brain
“Cold Turkey”
0
1
2
3
4
Days
5
6
7
8
9
10
Usual Level
HELP. HOPE. HEALING.
Ultra Rapid Detox
Level of
Opiates
in Brain
“Cold Turkey”
0
1
2
3
4
Days
5
6
7
8
9
10
Usual Level
Ultra Rapid Detox
HELP. HOPE. HEALING.
Accelerated Detox
Level of
Opiates
in Brain
“Cold Turkey”
0
1
2
3
4
Days
5
6
7
8
9
10
Usual Level
Ultra Rapid Detox
HELP. HOPE. HEALING.
Accelerated Detox
Level of
Opiates
in Brain
Light Sedatives
“Cold Turkey”
0
1
2
3
4
Days
5
6
7
8
9
10
Usual Level
Ultra Rapid Detox
HELP. HOPE. HEALING.
Accelerated Detox
Level of
Opiates
in Brain
Light Sedatives
“Cold Turkey”
0
1
2
3
4
Days
5
6
7
8
9
10
Usual Level
Ultra Rapid Detox
HELP. HOPE. HEALING.
Accelerated Detox
Level of
Opiates
in Brain
Light Sedatives
Induction onto full dose Naltrexone under
light sedation
“Cold Turkey”
0
1
2
3
4
Days
5
6
7
8
9
10
Usual Level
Ultra Rapid Detox
HELP. HOPE. HEALING.
Accelerated Detox
Level of
Opiates
in Brain
Light Sedatives
Microdose Naltrexone
Induction onto full dose Naltrexone under
light sedation
“Cold Turkey”
0
1
2
3
4
Days
5
6
7
8
9
10
HELP. HOPE. HEALING.
Our Facilities Provide a Nice Level of Patient
Comfort…
23
HELP. HOPE. HEALING.
Naltrexone Therapy
•
Naltrexone Implants
• We have used implants for over 16 years, in thousands of
patients
• Provides 2 months of reliable blockage
• Most patients report no cravings
• Can be easily replaced and therapy continued as needed
• Low side effects
•
Naltrexone Monthly Injections
• Vivitrol has recently been approved for use
• Monthly injection and very reliable
• Can be very expensive, but is sometimes covered by
insurance
Naltrexone Implants
HELP. HOPE. HEALING.
What They Are
When To Use
• 2 month duration
• Recommend minimum of 12
months
• Minor surgical procedure
• Infection rate < 2%
• After each detox
• If self-detoxed / detoxed
elsewhere
• While in treatment
• After period of incarceration
• Patient on probationary period
HELP. HOPE. HEALING.
Naltrexone Therapy Provides a “Window of
Opportunity” for Patients to Initiate Change
HELP. HOPE. HEALING.
Our Implant Room and Nurses Station
Naltrexone can be a Physical Bridge to
Long Term Recovery
HELP. HOPE. HEALING.
•
•
•
•
•
•
•
•
Full Acceptance of the illness – surrender?
Understanding the illness
Understanding Cravings and Relapse
Ability to deal with emotions
Avoiding triggers by changing people, places and
things
Relationship growth
Career growth
Spiritual growth
HELP. HOPE. HEALING.
Rehabilitation Programs – Match Intensity to the
Patient’s Need
•
Extended Care – usually 3-12 months
•
Recovery Residences
•
28 day Inpatient Rehabilitation Programs
•
IOP – Intensive Outpatient Programs
•
Individual Therapy
HELP. HOPE. HEALING.
QUESTIONS?